What working on the frontline of Ebola has taught me about the need for sexual & reproductive health in public health emergencies
“Our people are still prepared to come to work knowing that life on the frontline isn’t straightforward.”
I was sent to Liberia in West Africa to respond to an outbreak of Ebola, a form of hemorrhagic fever that is very severe. The outbreak started in December 2013 in the country next door to Liberia. By March of the next year, it had made its way to the capital, and by September things were completely out of control. Ebola had been mistaken as a severe form of malaria and several health workers had become sick and were dying.
There was worry in the informal settlements as there was no access to formal healthcare, and heartbreakingly, in this day and age, despite calling for international assistance and the aid community doing our very best, some days there just wasn’t enough beds to care for the patients.
One of the things that we noticed was that there were really sick people presenting to our Ebola treatment centres, who didn’t have Ebola. These people were so desperate to access healthcare, no matter what the risks. Imagine going to an Ebola treatment center when you know you have severe malaria, but knowing that there is nowhere else to go?
We realised there were a lot of people dying from non- Ebola-related causes, so we had to be innovative and we had to work quickly. A couple of priorities that we realised were to treat malaria, an endemic disease that can be fatal. So, we gave everyone in the whole city basic hygiene resources and malaria treatment. Then it was my responsibility to set up a non-Ebola hospital for women and children in the middle of an Ebola outbreak! There was not the international guidance to do this like there is now, so we had to think things through carefully. But there was a huge need, and it was our job to respond to it.
The fragile healthcare system in Liberia had collapsed, everything was closed. There were no buses. No taxis. No healthcare services outside Ebola. No private hospitals. Other aspects that made it really tough for the community to access to sexual and reproductive healthcare was the ‘stay at home’ warning, and the fact that not even the pharmacies were open.
One of the reasons for this very sudden collapse was that in the early days was that some of the hospitals had unintentionally admitted patients who had Ebola. The consequence of this was that everyone had family and colleagues who had contracted the disease. Ebola has an up to 50% mortality rate and that was with treatment — the healthcare workforce was extremely concerned.
You can imagine the joy I felt when I was thinking about how, and where, and who will we set up this women’s and children’s hospital when I heard that sexual and gender-based violence (SGBV) response workers and HIV workers were prepared to get back to work as they felt a humanitarian imperative calling them.
We started with SGBV and HIV response services because we know that as clinicians, in an emergency, we are always thinking about what will save lives. So, we were focused on preventing the transmission and reducing the morbidity and mortality rates of HIV (and other STIs). For SGBV, we knew, unfortunately, that this is a common occurrence and increases during crisis settings. Other life-saving interventions I was planning was to support new-born morbidity and mortality by giving women a safe place to give birth.
One of the key learnings I found from setting up the women’s and children’s facility in Liberia was engaging the community at a broader level was really the key to stopping the spread of the virus. This is no easy feat. It is not easy to get people to change their local and cultural behaviours overnight. The way you greet someone — the way you eat together — the way you defecate — the way you grieve and bury your loved ones — even the way you care for them. Community understanding and acceptance of what is happening now and what the pathway forward is key.
Another key learning is that we cannot stop providing other lifesaving activities because we have this overwhelming public health emergency, because people will die if their needs are not provided for. By that I mean, excess maternal mortality, people who cannot access their HIV treatment, people who experience gender-based violence and find themselves with an unintended pregnancy.
Sadly, I was witness to several unsafe abortion practices. The use of traditional healers in Liberia is common due to the lack of healthcare available. There were several instances of young women relying on very harmful practices to end their pregnancies.
You can imagine how motivated I was to get the message out there that our clinic was up and running and safe. We had to make sure women were able to get there, including safe transport system. But yet, even though I was there for a relatively short time, I can only imagine the increase in the community in these unsafe practices overall.
For me, I see several similarities between COVID-19 and Ebola. One is the healthcare system has been completely overwhelmed in many countries leaving people with little or no sexual and reproductive healthcare. Sexual and reproductive healthcare (SRH) drops down the list of priorities when a pandemic occurs.
The other is that women take the lead as the caregiving role for the sick. Another one — which IPPF is addressing — is the hunger for more information from the community.
The other clear parallel between COVID-19 and Ebola is how communities have been asked to change their behaviour overnight. To change the way we show affection, eat, and change of course how we care for our sick, elderly and dying.
But one of the positive parallels I see is the innovation and resilience of communities. How they stay together whilst living apart. In low resource settings, it’s through the radio. In other settings, it’s clapping from the balconies. I saw it then — and I see it now.
What can we do now?
It’s very encouraging to see that SRH is being recognised as an essential service in many of the countries in which IPPF works. This is the first step in ensuring access for the women and girls, men and boys, who need our care.
We have to realise that some of our services are needed in this crisis more than others, such as support for survivors of SGBV. The words “essential service” keeps coming to my mind. Knowing that our outreach interventions that we do now, are actually lifesaving.
My advice for SRH organisations is to talk within your teams to ensure people know what we are doing and why we are doing it, and how to do our work safely. And then to send that message out to communities to let them know that we are here for you. Albeit, we night be operating slightly differently. But we are still here to support you.
I am so proud of so many of our Member Associations. I want to recognise that we are all going through a tough time with COVID-19. In our home life as well as our work life. But the flexibility and speed in which we have adapted to our health provision has made me really proud to work for IPPF. I’m proud to see that we have support for keeping everyone safe. We are going digital — opting for telemedicine. I am loving the e-shops and home delivery of supplies to people in need. And that our people are still prepared to come to work knowing that life on the frontline is not straightforward.
Words by Monica Burns, SRH Advisor (Pacific), IPPF Humanitarian Hub